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journal homepage: www.intl.elsevierhealth.com/journals/dema

Fatigue resistance of CAD/CAM resin composite

molar crowns

Fatma A. Shembish a , Hui Tong a,b , Marina Kaizer a,c , Malvin N. Janal d ,
Van P. Thompson e , Niek J. Opdam f , Yu Zhang a,∗
a Department of Biomaterials and Biomimetics, New York University College of Dentistry, 433 First Avenue,
New York, NY 10010, USA
b School of Metallurgy and Environment, Central South University, Changsha, Hunan 410083, PR China
c Graduate Program in Dentistry, Federal University of Pelotas, Pelotas, Brazil
d Department of Epidemiology and Health Promotion, New York University College of Dentistry, 380 Second Avenue

Suite 301, New York, NY 10010, USA

e Tissue Engineering and Biophotonics, King’s College London Dental Institute, United Kingdom
f Radboud University Nijmegen Medical Centre, College of Dental Sciences, Preventive and Restorative Dentistry,

Ph van Leydenlaan 25, PO Box 9101, 6500HB Nijmegen, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: Objective. To demonstrate the fatigue behavior of CAD/CAM resin composite molar crowns
Received 27 June 2015 using a mouth-motion step-stress fatigue test. Monolithic leucite-reinforced glass-ceramic
Received in revised form crowns were used as a reference.
3 November 2015 Methods. Fully anatomically shaped monolithic resin composite molar crowns (Lava Ulti-
Accepted 7 December 2015 mate, n = 24) and leucite reinforced glass-ceramic crowns (IPS Empress CAD, n = 24) were
Available online xxx fabricated using CAD/CAM systems. Crowns were cemented on aged dentin-like resin
composite tooth replicas (Filtek Z100) with resin-based cements (RelyX Ultimate for Lava
Keywords: Ultimate or Multilink Automix for IPS Empress). Three step-stress profiles (aggressive, mod-
Fatigue erate and mild) were employed for the accelerated sliding-contact mouth-motion fatigue
Fracture test. Twenty one crowns from each group were randomly distributed among these three
Resin composite profiles (1:2:4). Failure was designated as chip-off or bulk fracture. Optical and electron
Glass-ceramic microscopes were used to examine the occlusal surface and subsurface damages, as well as
CAD/CAM crowns the material microstructures.
Weibull analysis Results. The resin composite crowns showed only minor occlusal damage during mouth-
motion step-stress fatigue loading up to 1700 N. Cross-sectional views revealed contact-
induced cone cracks in all specimens, and flexural radial cracks in 2 crowns. Both cone and
radial cracks were relatively small compared to the crown thickness. Extending these cracks
to the threshold for catastrophic failure would require much higher indentation loads or
more loading cycles. In contrast, all of the glass-ceramic crowns fractured, starting at loads
of approximately 450 N.

∗
Corresponding author. Tel.: +1 212 998 9637; fax: +1 212 995 4244.
E-mail address: yz21@nyu.edu (Y. Zhang).
http://dx.doi.org/10.1016/j.dental.2015.12.005
0109-5641/© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Shembish FA, et al. Fatigue resistance of CAD/CAM resin composite molar crowns. Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.12.005
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Significance. Monolithic CAD/CAM resin composite crowns endure, with only superficial dam-
age, fatigue loads 3–4 times higher than those causing catastrophic failure in glass-ceramic
CAD crowns.
© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.
1. Introduction
In clinical dentistry, there is a shift toward placing metal-
free restorations. For direct restorations, resin composite has
become the standard material that, depending on risk fac-
tors of tooth and patient, provides restorations with good
longevity [1–3]. Indirect restorations allow the dentist to have
greater control of the form and function of a restoration,
especially for teeth with considerable amount of tooth sub-
stance loss. For indirect restorations, several types of ceramic
restorative materials have shown good survival rates when
applied as full coverage crowns or inlays, although chipping
of the ceramic remains a common problem [4,5]. Indirect
resin composite restorations have shown acceptable surviv-
ability [6,7], but their performance is not better than direct
restorations [8]. The increased use of resin composite materi-
als for indirect restorations is a result of several recent trends:
significant improvements in their mechanical properties,
increased demands for highly esthetic, metal-free, biocompat-
ible restorations [9,10], and rapid advances in computer-aided
design/computer-assisted manufacturing (CAD/CAM) tech-
nology. Recently, resin composite blocks have been introduced
for use with CAD/CAM systems as an alternative for machin-
able ceramics [11]. CAD/CAM resin composite restorations
have several advantages over their ceramic counterparts: (1)
Resin composite blocks are milling damage tolerant, which
allows for a faster milling speed and provides better marginal
quality [12]; a full contour crown takes only 6 min to mill [13]!
(2) No post-milling firing is needed. (3) Indirect resin compos-
ite restorations can be easily polished and adjusted for proper
occlusion. These properties permit the fabrication and place-
ment of a complete restoration within a single dental office
visit [13,14], benefiting both the patient and practitioner.
Much effort has been made to improve the mechanical
properties of resin composite restorative materials, such as
increased filler content, changes in filler particle size and
shape, changes in matrix composition, and improvements
of polymerization methods [15–19]. Recently, nanotechnology
has been introduced to the dental resin composite man-
ufacturing field. One recently developed nanohybrid resin
composite material is Lava Ultimate CAD/CAM Restorative
(3 M ESPE, St. Paul, MI, USA); it is heat-cured through a pro-
prietary manufacturing process, which eliminates the need
for any further polymerization after milling.
Several in vitro studies have evaluated indirect resin com-
posites. Magne and colleagues conducted a number of studies
on Paradigm MZ100 (3 M ESPE) [20–22]. They compared the
fatigue resistance of resin composite and ceramic occlusal
veneers and onlays with various thicknesses on posterior
teeth (some with endodontic treatments). They reported that
posterior occlusal veneers and onlays made of MZ100 had
Please cite this article in press as: Shembish FA, et al. Fatigue resistance of CAD/CAM resin composite molar crowns. Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.12.005
significantly higher fatigue resistance compared to IPS
Empress CAD (Ivoclar Vivadent, Schaan, Liechtenstein), IPS
e.max CAD (Ivoclar Vivadent), and Vitablocks Mark II (VITA
Zahnfabrik, Bad Säckingen, Germany). Kassem et al. [23]
examined the effect of cyclic loading using a hardened steel
ball (r = 3 mm) on fatigue resistance and microleakage of
monolithic CAD/CAM molar ceramic and resin composite
crowns. Their results revealed that MZ100 resin composite
molar crowns were more fatigue resistant than Vitablocks
Mark II ceramic crowns, after 1,000,000 cycles of cyclic loading
at 600 N. However, ceramic crowns exhibited significantly less
microleakage relative to resin composite crowns, irrespective
of the type of the cement used. Belli et al. [24] compared the
fatigue resistance of modern dental ceramic bar specimens
versus resin composites using the 4-point bending method.
Their results revealed that while resin composite and dental
ceramics exhibit similar fatigue degradation, resin compos-
ite materials used for direct restorations are more resistant to
cyclic flexural loading than glass-rich ceramics used for indi-
rect restorations. Johnson et al. [25] showed superior fracture
strength of posterior occlusal veneers made from Lava Ulti-
mate resin composites than Paradigm MZ100 and concluded
that Lava Ultimate were able to survive higher occlusal loads
than MZ100.
By introducing the new and improved indirect nanohybrid
resin composite material, the clinical indications of CAD/CAM
resin composite restoration have been extended to full cov-
erage posterior crowns, which require greater mechanical
integrity than inlays and onlays. However, to our knowledge,
no in vitro fatigue study has been conducted on full-coverage
posterior nanohybrid resin composite crowns. The purpose
of this in vitro study is, therefore, to investigate the sliding
contact mouth-motion fatigue behavior and reliability of a
newly developed indirect nanohybrid resin composite (Lava
Ultimate) for posterior crown applications.
2. Materials and methods
2.1. Crown fabrication
Anatomically correct mandibular first molar crowns (n = 24,
resin composite Lava Ultimate crowns; n = 24, glass-ceramic
IPS Empress CAD crowns) were designed and milled from
CAD/CAM blocks using the following systems: Lava Milling
System (3M ESPE) in a 3M certified dental lab (Jensen Den-
tal, North Haven, CT) and CEREC System (Sirona, Charlotte,
NC, USA). A standard die of a mandibular first molar prepa-
ration was scanned into the system adjusted to compensate
for the cement layer thickness (50 ␮m). Tooth preparation was
modeled by reducing the proximal walls by 1.5 mm and the
occlusal surface by 2.0 mm. After milling the crowns were
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processed according to the manufacturer recommendation: (1)
Lava Ultimate – polished with Meisinger Luster and diamond
paste (Meisinger, Centennial, CO, USA); (2) IPS Empress CAD –
glazed with IPS Empress Universal Glaze (Ivoclar Vivadent).
2.2. Cementation procedure
All crowns were cemented to aged (stored in distilled water
at 37 ◦ C for at least 21 days) resin composite dies (Filtek Z100,
3M ESPE). All cementation procedures followed the manufac-
turers’ instructions. Z100 was selected as abutment material
because it has an elastic modulus of 18 GPa [26,27], which
is similar to the elastic modulus of 16–18 GPa for human
dentin [28,29]. The effective elastic modulus of the suppor-
ting abutment and the luting cement has been found to play a
governing role in the fracture resistance of the crown [30,31].
(i) Lava Ultimate cementation: Prior to cementation all Z100
abutments were thoroughly cleaned with 70% ethyl alco-
hol and air dried, followed by application of Scotchbond
Universal Adhesive (3M ESPE), rubbing it for 20 s and air
dried for 5 s. The crowns were cleaned in ultrasonic bath
and air dried. The bonding surfaces of the resin com-
posite crowns were sandblasted using aluminum oxide
particle (50 ␮m at 2 bars), avoiding crown margins until the
entire bonding surface appears matte. Crowns were then
thoroughly cleaned with 70% ethyl alcohol and air dried.
Scotchbond Universal Adhesive was applied to the bond-
ing surface of the crown, scrubbed in for 20 s, and air dried
for 5 s. The luting agent used was RelyX Ultimate (3M ESPE)
dispensed by the mixing tip inside the crown. The crown
was then firmly seated and stabilized onto the abutment.
The excess cement was chipped away after brief light cur-
ing. Polymerization of the luting agent was carried out by
using a dental curing light (Ultra Lume LED 5), exposing
each surface of the crown for 20 s.
(ii) IPS Empress CAD cementation: Z100 abutments were also
cleaned with 70% ethyl alcohol, followed by application
of Monobond Plus (Ivoclar Vivadent), 60 s waiting time,
and air dried. The bonding surfaces of the crown were
thoroughly cleaned with 70% ethyl alcohol, followed by
application of 5% hydrofluoric acid gel (Vita Ceramics Etch
– VITA) for 60 s, washed in tap water, and air dried for
20 s. Monobond Plus was applied, followed by 60 s waiting
time, and air drying. The luting agent used was Multilink
Automix system (Ivoclar Vivadent). The following steps
were identical to those described for the resin composite
crowns.
After cementation specimens were stored in distilled water
at 37 ◦ C for a minimum of 5 days for polymerization and hydra-
tion of the cement layer prior to mechanical testing.
2.3. Mechanical testing
2.3.1. Single cycle load to fracture test
To determine the accelerated sliding contact mouth-motion
step-stress profiles, three crowns per group were subjected to
the single cycle load to failure test [32,33]. The crown/tooth
replica assembly was mounted in a universal testing machine
Please cite this article in press as: Shembish FA, et al. Fatigue resistance of CAD/CAM resin composite molar crowns. Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.12.005
3
(Model 5566, Instron); load was applied axially through a tung-
sten carbide indenter (r = 3.18 mm) on the central fossa of the
occlusal surface using a 10 kN load cell and 1 mm/min load
rate.
2.3.2. Accelerated sliding contact mouth-motion
step-stress fatigue test
Twenty one crowns from each group were subjected to
mouth-motion step-stress fatigue. Mechanical testing was
performed by sliding a spherical tungsten carbide (WC) inden-
ter (r = 3.18 mm) 0.7 mm down the distobuccal cusp toward the
central fossa, using an electrodynamic fatigue testing machine
(Elf-3300, Enduratec Division of Bose, Minnetonka, MN, USA).
Crowns were immersed in distilled water during fatigue test-
ing [33].
Three step-stress profiles (aggressive, moderate, and mild)
were designed for fatigue testing [33]. The 21 crowns per group
were distributed across the three profiles in the ratio of 1:2:4,
aggressive to mild, respectively, based upon the load to frac-
ture experiments. For the resin composite crowns the mild
profile started at 400 N indentation load and went to 1200 N
at 170,000 cycles; the moderate profile started at 500 N and
went to 1400 N at 120,000 cycles; the aggressive profile at
600 N and went to 1700 N at 90,000 cycles. Whereas for the
glass-ceramic crowns, the mild profile started with a 50 N
indentation load based on the load-to-fracture experiments
and load was increased by predetermined steps until fracture.
Similarly, for the moderate and aggressive profiles, indenta-
tion load started at 100 N and 150 N, respectively, and was
increased successively until fracture.
It is well-established that ceramic [34] and composite [35]
materials are sensitive to load/stress rate. Therefore, in the
current fatigue test, a clinically relevant load rate (1000 N/s)
was utilized [36,37]. As a result, the loading frequency, includ-
ing load, slide and lift-off phases, varied from 0.3 Hz at 1700 N
to 3 Hz at 100 N.
At the end of each load cycle, all specimens were inspected
under polarized light stereomicroscopy for cracks and dam-
age. Bulk fracture and chip-off fracture of the crowns were
considered as failures. A Weibull curve and reliability for com-
pletion of a mission of 100,000 cycles were calculated (ALTA 7
PRO, Reliasoft) for the glass-ceramic group only (resin com-
posite group did not present failures during step-stress tests).
2.4. Microscopic imaging analysis
After mouth-motion step-stress fatigue tests, all crowns that
did not present fracture (from the resin composite group only)
were firstly examined for occlusal surface damage associated
with the fatigue scar and its surrounding areas using polarized
light stereomicroscopy (Leica MZ-APO, Wetzlar, Germany). Fif-
teen specimens were then embedded in the clear epoxy resin,
sectioned, and polished (all 12 samples from the mild profile
& 3 samples from the aggressive profile) to evaluate the extent
of subsurface damage. Sectioning took place along the direc-
tion of sliding contact and slightly away from the center of
the fatigue scar, using a water cooled low speed diamond saw
(Isomet, Buehler, Lake Buff, IL). The cross-sections were pol-
ished up to the center of the fatigue scar with a 1 ␮m diamond
suspension finish and analyzed using optical and scanning
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Fig. 1 – Microstructure of the resin composite Lava Ultimate (left) and the glass-ceramic IPS Empress CAD (right, courtesy of
Ivoclar). Both materials were polished down to 1 ␮m prior to imaging. In addition, IPS Empress CAD surface was acid etched
with 40% hydrofluoric vapor (20 s) to allow a better examination of the crystalline content.
electron microscopes for the presence of cracks and damage.
Measurements of the actual length and depth of contact-
induced partial cone cracks, median cracks, inner cone cracks,
and flexural-induced cementation surface radial cracks were
performed using Leica QWin software in a polarized light
stereomicroscope (Leica MZ-APO). In addition, scanning elec-
tron microscopy (SEM, S-3500N, Hitachi Instruments, Tokyo,
Japan) was utilized to observe the microstructure of the two
materials tested and the interaction between the cracks and
the microstructural features.
At the end of fatigue loading, we evaluated latent dam-
age in survivors using a sectioning technique [38] rather than
a residual strength measurement using the monotonic load
to failure test [39–41]. We believe that more information can
be gleaned by identifying surface and subsurface structural
changes than from very high load fracture patterns or reduc-
tion in initial strength.
3. Results
The microstructures of the resin composite Lava Ultimate
and the glass-ceramic IPS Empress CAD are shown in Fig. 1.
SEM and EDS analyses revealed that the microstructure of
the resin composite material consisted of a polymer matrix
with high ceramic filler loading (Fig. 1a). However, due to the
relatively low magnification of our SEM, only the nanoparti-
cle clusters of silica and zirconia were observed, which were
in the range of 0.6–10 ␮m. It was not possible to identify
the dispersed silica and zirconia nanoparticles described by
the manufacturer of this material (silica particles ≈ 20 nm,
zirconia particles ≈ 4–11 nm). The microstructure of the glass-
ceramic consisted of a glassy matrix with evenly distributed
leucite crystals (Fig. 1b). The diameter of these crystals was
about 1–5 ␮m; the crystal content was 35–45% by volume.
The results of the single cycle load to fracture test are pre-
sented in Table 1. The mean (± SD) critical load at fracture
for resin composite crowns was 3271 ± 143 N, whereas that for
glass-ceramic crowns was 1465 ± 222 N. Both materials, how-
ever, showed the same pattern of fracture – splitting of the
crown in the middle through proximal surfaces (Fig. 2). Fol-
lowing mouth-motion fatigue with predetermined step-stress
profiles, resin composite crowns had a survival rate of 100%,
no catastrophic failures. Despite the very high indentation
Please cite this article in press as: Shembish FA, et al. Fatigue resistance of CAD/CAM resin composite molar crowns. Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.12.005
Table 1 – Maximum flexure load (N) for three specimens
of each group.
Lava Ultimate IPS Empress CAD
Load (N) 3378 1275
3325 1410
3108 1709
Mean ± SD (N) 3271 ± 143 1465 ± 222
loads (up to 1700 N), only minor occlusal damage was observed
(Fig. 3a).
Careful examination of the resin composite crowns from
the occlusal aspect revealed two fatigue damage modes:
sliding-contact induced occlusal surface herringbone cracks
on the distobuccal cusp [31,42]; and, impact induced concen-
tric ring cracks on the distolingual cusp [43,44]. Under the
cyclic loading in wet environments, both herringbone and ring
cracks are capable of propagating deep into the material, form-
ing partial [26,33] and inner cone cracks, respectively [45]. Only
one crown among 21 specimens, from the aggressive profile,
experienced minor spalling at the leading edge of the sliding
contact (Fig. 3b).
To determine the occlusal crack depth and whether
the flexure-induced cementation surface radial cracks were
formed, all 12 crowns from the mild profile (higher number
of loading cycles) and all 3 crowns from the aggressive profile
(higher level of indentation load) were sectioned. Stereomi-
croscopic images showed several types of damage modes in
the resin composite crowns: distobuccal cusp sliding-induced
occlusal surface partial cone cracks [31] (Fig. 4a) in all sectioned
crowns; median cracks [26] (Fig. 4b) in 5 crowns; distolin-
gual cusp impact-induced inner cone cracks [46,47] (Fig. 4c) in
7 crowns; flexure-induced cementation surface radial cracks
[34,48,49] (Fig. 4d) in 2 crowns; and minor spalling associated
with the sliding-contact fatigue scar [50] (Fig. 4e) in 1 crown.
The lengths for different types of cracks in the resin com-
posite crowns are given in Table 2. It is important to note
that the crack lengths for various crack systems were mea-
sured near the center of the fatigue scar on the cross-sectional
specimens. They are not necessarily representing the longest
crack length of each crack system. Fig. 5 shows one of the
radial cracks observed in the resin composite crowns. This
crack appeared to form at the cement/Z100 interface and was
associated with a large defect in Z100 abutment which com-
promised the structural support of the cement layer. The crack
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Fig. 2 – Single cycle load-to-failure fracture modes. (a and c) Resin composite crown (3271 ± 143 N). (b and d) Glass-ceramic
crown (1465 ± 222 N).

ran across the cement layer, reinitiated in the resin composite SEM micrographs showing the interaction between the
crown structure, and propagated upward and sideward. Quan- crack and the microstructure of the resin composite material
titative imaging analysis showed the crack length to be about appear in Fig. 6. Lava Ultimate restorative is a blend of 80 wt.%
1000 ␮m, about half the thickness of the crown. ceramic fillers embedded in a highly cured resin matrix. The

Fig. 3 – (a) Occlusal view of a resin composite crown from the mild profile (indentation load of 1200 N at 170 K loading
cycles). (b) Details of the fatigue scar in a resin composite crown from the aggressive profile (indentation load of 1700 N at
90 K cycles). Note in (b): minor spalling measuring 1255 ␮m and 1796 ␮m in the bucco-lingual and mesio-distal directions,
respectively.

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Fig. 4 – Damage modes in resin composite crowns. (a) Sliding contact induced partial cone cracks. (b) Occlusal contact
induced median cracks. (c) Impact induced inner cone cracks. (d) Flexure induced cementation surface radial cracks. (e)
Minor spalling (Depth ∼ 300 ␮m).

ceramic fillers are made up of three different ceramic par-
ticles: highly dispersed silica particles (20 nm) and zirconia
particles (4–11 nm), and aggregated zirconia/silica clusters
(0.6–10 ␮m), comprised of 20 nm silica and 4 to 11 nm zirconia
particles. At the micro-fracture scale, crack interaction with
the zirconia/silica clusters varied with the crack incidence
angle. When the crack intersected the nanoparticle cluster at
an acute angle, it often propagated or deflected around the
cluster (Fig. 6a), suggesting some toughening mechanisms in
these highly filled resin composites. However, when the crack
encountered the cluster at a high angle, the crack penetrated
through the nanoparticle cluster (Fig. 6b).
Using a cumulative damage model with power law relation-
ship, the 2-parameter Weibull load – failure probability plot
was generated for the glass-ceramic crowns using the mouth-
motion step-stress fatigue data (Fig. 7). Reliability (two-sided at
90% confidence bounds) for completion of a mission of 100,000
cycles at 400 N indentation load was 0.773 (0.867–0.673). How-
ever, when the indentation load was increased to 600 N,
reliability was reduced to 0.171 (0.293–0.079). At a clinically
relevant load of 200 N, the survivability of IPS Empress CAD
molar crowns was 90% at 1,250,000 cycles, which simulates
∼5 years in vivo.
Stereomicroscope images of a typical fracture pattern in
the glass-ceramic crowns are shown in Fig. 8 (a) occlusal
view and (b) buccal view. In this specimen, fracture occurred
following mouth-motion step-stress fatigue at 475 N/220,000
cycles. The fracture had a typical scallop-shaped morphology

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Table 2 – Lava Ultimate CAD crack modes and length.

Sample (mild profile) Sliding induced occlusal cracks Impact induced Flexural cementation
inner cone cracks surface radial cracks
beneath impact cusp

Partial cone Median cracks

cracks
Sample 1 219 ␮m 146 ␮m 142 ␮m x
Sample 2 117 ␮m 965 ␮m x 1/10 of crown thickness (180 ␮m)
Sample 3 421 ␮m x x x
Sample 4 365 ␮m x 207 ␮m 1/2 of crown thickness (1006 ␮m)
Sample 5 269 ␮m x 127 ␮m x
Sample 6 158 ␮m x x x
Sample 7 168 ␮m 467 ␮m x x
Sample 8 268 ␮m 195 ␮m 129 ␮m x
Sample 9 162 ␮m x 108 ␮m x
Sample 10 251 ␮m x 296 ␮m x
Sample 11 326 ␮m x x x
Sample 12 230 ␮m x x x

fractured glass-ceramic crowns, the chip-off fracture involved

two cusps (distobuccal cusp and distal cusp). To confirm that
glass-ceramic crowns failed exclusively from the chip-off frac-
ture associated with the occlusal contact, 8 crowns (especially
those fractured at higher indentation loads, i.e. >550 N) were
sectioned along the sliding contact direction and across the
fatigue scar. No radial fractures were observed.
During the mouth-motion step-stress fatigue of the glass-
ceramic crowns, cracks initiated at the occlusal contact area
and propagated as the indentation load and number of load-
ing cycles increased. Once these cracks reached a critical size
(often longer than 5 mm), the next loading step often resulted
in chip-off fracture. Two crowns that developed extensive
crack formation were sectioned before a chip-off fracture
occurred. Both of these cracks extended deep into the mate-
rial, reaching the crown–cement–abutment interface (Fig. 8d).

Fig. 5 – Flexure induced radial crack in a resin composite

crown. Note: a large defect in the abutment compromises
the support for the cement. 4. Discussion

This in vitro study investigated the sliding-contact fatigue

with a maximum length (measuring from the occlusal sur-
face down the buccal wall toward margin) of approximately
5 mm and a width in the disto-mesial direction of approxi-
mately 5.5 mm. Closer inspection from the buccal aspect of
the crown (Fig. 8b) revealed multiple arrest lines, suggesting
the fracture originated at the occlusal contact point. The frac-
tured surface did not expose the Z100 abutment. In most of the
resistance and damage modes of a recently developed indi-
rect resin composite for CAD/CAM applications. The results
support the hypothesis that CAD/CAM resin composite molar
crowns have better fatigue fracture resistance than leucite
reinforced glass-ceramic molar crowns. Following the most
harsh step-stress profiles that the chewing simulator could
deliver (a maximum fatigue load of 1700 N), none of the
resin composite crowns experienced catastrophic failure. By

Fig. 6 – Crack interactions with nanoparticle clusters in the resin composite.

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99 contrast, no sample from the leucite glass-ceramic group sur-

vived at 650 N indentation loads.
90
Damage modes sustained in the CAD/CAM resin composite
crown/abutment system have been investigated: sliding-
contact induced partial cone cracks and impact induced inner
Failure probability (%)

50
cone cracks initiated at the occlusal surface and propagated
into but not through the restorative material (observed in
all cases). Flexure-induced radial cracks, only observed in
10 two cases, initiated at the cementation surface. While three
crack modes have been identified, the cracks were relatively
5 small compared to the crown thickness even after 1200 N
and 170,000 loading cycles. Sliding contact partial cone cracks
(100–500 ␮m), which are about 1/10–1/4 of crown thickness
(2000 ␮m). Impact induced inner cone cracks (100–300 ␮m) that
1
100 200 300 500 700 1000 are about 1/10–1/5 of the same crown thickness. Two cases of
Load (N) radial cracks, however, are approximately 1/10 and 1/2 of the
crown thickness, respectively. The propagation of these near-
Fig. 7 – IPS Empress CAD failure probability (Weibull contact induced cone cracks and far-field flexural radial cracks
distribution) versus load with 90% two-sided confidence leading to chip-off and bulk fractures of the indirect resin com-
bounds (dashed lines). posite crowns would require higher indentation loads or larger
number of loading cycles [51].
The glass ceramic crowns all failed in the form of chip-
off fractures during mouth-motion step-stress fatigue at an

Fig. 8 – (a) Occlusal view and (b) buccal view of a typical fracture pattern of the glass-ceramic materials (indentation load of
475 N at 220,000 loading cycles). (c) Occlusal view and (d) section view of a glass-ceramic crown (indentation load of 550 N at
250,000 loading cycles) exhibiting extensive crack formation.

Please cite this article in press as: Shembish FA, et al. Fatigue resistance of CAD/CAM resin composite molar crowns. Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.12.005
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indentation load level of 450 N or higher. A 90% survival rate
was estimated for a mission of 1,250,000 cycles at 200 N, which
is equivalent to ∼5 years of clinical survival in occlusal func-
tion [52,53]. A systematic review by Heintze and Rousson [54]
included seven clinical studies involving 1487 adhesively luted
IPS Empress crowns concluded that the hazard for failure for
these crowns was 16 in every 1000 crowns per year for molars.
This indicates that Empress CAD crowns have good clinical
performance, with the main reported cause for clinical failure
being chipping fractures. Similarly, in the present study, all
glass-ceramic crowns failed by chipping fractures, indicating
some clinical relevance of the applied test set-up.
These results are consistent with other studies showing
mechanical robustness of indirect resin composite materi-
als compared to ceramic materials. Magne and coworkers
[20,21] conducted series of studies on the fatigue fracture resis-
tance of CAD/CAM resin composite (Paradigm MZ100). They
showed that the fatigue resistance of Paradigm MZ100 poste-
rior occlusal veneers with various thicknesses outperformed
their ceramic (IPS Empress CAD or IPS e.max CAD) coun-
terparts. Present findings are also supported by Johnson
et al. [25], who determined the effect of material type and
restoration thickness on the fracture strength of posterior
occlusal veneers made from computer-milled resin com-
posite materials (Paradigm MZ100 and Lava Ultimate). The
authors reported that occlusal veneers made from the resin
composites tested are likely to survive the occlusal forces
regardless of restoration thickness, with those fabricated from
Lava Ultimate being more likely to survive higher loads [25].
Kassem et al. [23] also studied the effect of compressive
cyclic loading on the fatigue resistance and microleakage
of monolithic CAD/CAM molar ceramic and resin compos-
ite crowns, and observed that all resin composite crowns
survived after 1,000,000 cycles of compressive cyclic loading,
more fatigue resistant than VMII (VITABLOCK Mark II) ceramic
crowns.
The main reasons possibly related to the excellent fatigue
reliability of the CAD/CAM nanohybrid resin composite in this
study are: Firstly, high filler loading which is made possible
by a hybrid structure consisting of extremely small discrete
nanoscale particles (4–20 nm) and clusters of nanoparticles
(0.6–10 ␮m) [55]; secondly, the CAD/CAM process uses blocks,
which are manufactured under the standard conditions, pro-
ducing a more homogeneous, dense and reliable material [12];
finally, due to the similar elastic modulus of the restorative
material to the effective modulus of abutment (Z100) and
resin-based cement, extremely high indentation loads are
required to initiate flexure-induced radial cracks at the cemen-
tation surface.
The results of this in vitro study have demonstrated that
indirect resin composite molar crowns have excellent resis-
tance to contact fatigue damage. These findings suggest a level
of fracture resistance that may be clinically acceptable. Since
molar crowns are subjected to high chewing stresses, they
are vulnerable to fracture. Therefore, this newly developed
CAD/CAM nanohybrid material can be indicated for posterior
crown applications as it meets the mechanical requirements
for high stress bearing areas. Until now, no clinical studies
for this crown material have been published to confirm this
assumption.
Please cite this article in press as: Shembish FA, et al. Fatigue resistance of CAD/CAM resin composite molar crowns. Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.12.005
9
During the development of this manuscript, 3M ESPE has
announced the removal of the full coverage crown indication
for Lava Ultimate due to a higher than anticipated debond-
ing issue, whereas this product continues to be indicated for
inlays, onlays, and veneer restorations. Since Lava Ultimate
has demonstrated a superior resistance to fatigue fracture,
future research should focus on the resin bond property of
this material in order to extend its clinical indications to full
coverage crowns.
Due to the high fatigue fracture resistance presented by
Lava Ultimate crowns, this material may be indicated for
patients with parafunctional activity. Manifestation of brux-
ism can be grinding or clenching, both generating high
loads/stresses onto the dental structures and restorations.
Although Lava Ultimate CAD/CAM Restorative was able to
withstand parafunctional-like high occlusal loading, it would
still be a challenge to test these materials in overlay restora-
tions when patients with severe tooth wear need to be restored
in increased vertical dimension by a minimally invasive tooth
preparation. In those bruxing patients, grinding comprises
the majority of the sliding component of chewing (i.e. no
food bolus between teeth, thus causing direct tooth to tooth
contact). Tooth loading at 1000–1400 N would correspond to
extreme situations with high extrinsic forces (trauma) [22,56]
or intrinsic masticatory accidents (under chewing loads but
delivered to a small area due to a hard foreign body such
as a pit or seed, for example). However, when the restorative
design is changed from a crown toward a less retentive over-
lay restoration, more attention has to be paid to the quality of
the cement-interface and minimal thickness of the material
as this might influence the strength of the tooth restorative
complex [57].
While it is clear that composites can undergo degradations
in structural and bonding properties due to temperature, pH,
and bacterial and enzymatic activities [58–60], such multifac-
torial effects are beyond the scope of this study. We feel that it
is extremely important to first establish the true fatigue per-
formance of the composites before any significant degradation
occurs. The results obtained from such study can serve as a
reference for comparison with future multifactorial studies.
The accelerated step-stress fatigue test has been used to
predict the failure probability of dental restorative materials
by various research groups [61–63]. This method has been vali-
dated by in vitro tests [62] and step-stress fatigue failure modes
mimicked those seen clinically [64,65]. Based on these obser-
vations, the objective of this study was to elucidate the fatigue
behavior of CAD/CAM resin-based composite relative to glass-
ceramic molar crowns. Ultimately, clinical trials will be needed
to establish whether these materials are able to function clin-
ically.
5. Conclusions
Monolithic Lava Ultimate resin composite CAD/CAM crowns
can endure exceptionally high fatigue loads. Several fatigue
damage modes were noted: sliding-induced partial cone
cracks, impact-induced inner cone cracks, and flexure-
induced cementation surface radial cracks. All of these
damages were contained within the restoration. None of these
DENTAL-2692; No. of Pages 11
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resin composite crowns exhibited catastrophic failure. Under
present conditions, this nanohybrid indirect resin composite
material meets the mechanical requirements for high stress-
bearing posterior restorations, showing excellent resistance to
contact and flexural damage. If bonding issues can be resolved,
they offer an esthetic option for damage-resistant crowns in
the posterior regions of the mouth.
Conflict of interest
All authors declare no conflict of interest.
Acknowledgements
Certain results of this study (i.e. fatigue of Lava Ultimate
crowns) were submitted as part of a Master’s thesis by F. Shem-
bish in partial fulfillment of the requirements for a Master
of Science degree. This work was sponsored by funding from
the United States National Institute of Dental & Craniofacial
Research, National Institutes of Health (P.I. Y. Zhang, Grant
2R01 DE017925).
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